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| # | ||
|---|---|---|
| 1 | [Intake Case #] | Intake Case Number |
| 2 | [Version] | Version of the Case |
| 3 | [First Receipt Date] | First Receipt Date of the Case |
| 4 | [FU Receipt Date] | FU Receipt Date of the Case |
| 5 | [Primary Reporter] | Name of the Primary Reporter in format <First Name> <Middle Name> <Last Name> |
| 6 | [Patient Initials] | Name / Initials of the Patient |
| 7 | [Age] | Age of the Patient |
| 8 | [Gender] | Gender of the Patient |
| 9 | [Primary Suspect Product] | Name of the Primary Suspect Product in format <Trade Name> (<Generic Name>) if Product is coded else shall display the Product Name |
| 10 | [Primary Event] | Reported Reaction for first event in the case |
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